Laparoscopy has evolved since as early as 1950 to the present state of being the standard approach for most common surgical procedures. It has gained popularity in clinical practice in view of better cosmetics, lesser postoperative pain, shorter hospitalization, and faster recovery. However, the creation of pneumoperitoneum with laparoscopy is associated with various pathophysiological changes, especially involving the cardiovascular and respiratory systems. Electronic databases were searched to obtain the relevant literature with keywords related to laparoscopy from 1985 to 2016. Ninety-three papers were reviewed. Bibliographies were cross-checked and relevant literature was included. The pneumoperitoneum associated with laparoscopy is found to cause a decrease in cardiac output with an increase in pulmonary and systemic vascular resistance. These changes are mainly due to the increase in abdominal pressure which causes elevation of diaphragm with compression of small and big blood vessels. In the lungs, it causes a decrease in functional residual capacity with impaired pulmonary ventilation and perfusion. Increase in intra-abdominal pressure also perils the splanchnic circulation with a decrease in blood flow to the major abdominal organs. Preoperative assessment requires special attention, especially in high-risk patients. General anesthesia with controlled ventilation has proven to the ideal technique. Various pharmacological agents are used with varying success to attenuate the hemodynamic responses to laparoscopy. This article discusses the various consequences of laparoscopy as well as strategies to counteract them. It is essential for the anesthesiologists to have a good understanding of these changes and intervene at appropriate levels in terms of optimization in the preoperative period and management of hemodynamic changes in the perioperative period for a good surgical and patient outcome.

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The rise in popularity of bariatric surgery has been accompanied by a considerable increase in complications observed. Foot drop is a rare, but recognized complication after bariatric surgery. Early studies suggested the combination of rapid weight loss in the setting of postural compression of the nerve as main contributory factors. However, further research has also emphasized the role of postbariatric malnutrition and inflammation in the development of this neuropathy. The cause of this neuropathy is likely to be multifactorial, and understanding these mechanisms will assist multidisciplinary specialists in providing care to postbariatric patients suffering from this condition.

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As obesity is becoming a global epidemic, many solutions have been proposed to patients from medical to psychological to surgical. Recently, with the advances of laparoscopic surgery and the safety of the anesthesia, bariatric surgeries are expanding, particularly in the countries affected by obesity the most. Saudi Arabia is one of the highest countries with an obesity rate. This study aims to explore the complications of various bariatric surgeries (gastric banding, gastric bypass, and vertical sleeve gastrectomy) by reviewing the literature that has been published in Saudi Arabia. The findings from this study would enlighten the clinicians and patients about the prevalence of these complications in this geographical area and allow a thoughtful comparison between the complication rate among different countries and practice types.

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Revisional bariatric surgery is increasingly becoming popular as the number of primary procedures for the treatment of obesity gains popularity. It is estimated that about 10% of patients who underwent a bariatric procedure will need revisional surgery. The most common indications for revisional bariatric surgery are inadequate weight loss (<25% of excess body weight loss) and weight regain (gain of more than 10 kg based on the nadir weight); however, procedure-specific complications are also indication of the need for revisional surgery. In this article, we review the current most common bariatric procedures with its complications, indications for revision, alternative procedures, and outcomes.

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Background: Parturient undergoing elective cesarian delivery (CD) in a busy tertiary care referral hospital often requires blood transfusions. The preoperative ordering for blood crossmatch frequently overshoots the actual need of transfusion. Aims: The primary aim of this study was to audit the local blood ordering practice in obstetric anesthesia and compare with the international guidelines. Materials and Methods: A retrospective analysis of patients who underwent elective CD over a period of 6 months was done. The data collected included patients' age, pretransfusion hemoglobin, timing of transfusion, number of units crossmatched, and number of units transfused. The crossmatch transfusion ratio (CTR), transfusion probability, and transfusion index were calculated from the data. Results: A total of 425 patients underwent CD with mean age 33 (standard deviation 7). Seventy-seven (18%) of them were crossmatched with total 252 units. Thirty-one (7.3%) patients required transfusion and the number of units transfused was 79. CTR in our study was 3.2. Conclusion: CTR for elective CD is higher than the recommended international quality indicator value. There is a need to develop institutional specific blood ordering schedule to bring improvement in transfusion practices.

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Introduction: Surgical management of urinary stones has witnessed major development in the last few decades. After the successful introduction of Shock wave lithotripsy (SWL), the urologist's armamentarium for treating stones became versatile by adoption of rapidly evolving technologies that increasingly replaced the traditional open surgery.There are special situations when SWL and endourology is not the optimal choice and open surgery was the only option at a time, here comes the role of laparoscopy to replace the open surgery for dealing with these cases where endourology has major limitations. Hereby we will highlight the current international trend in laparoscopic surgery for urolithiasis and demonstrate our limited experience in laparoscopic stone surgery in ten patients in Aden, Yemen. Patient and Method: From March 2011 to September 2017. Ten consecutive patients' ages 4-60 years (mean 38 years) with renal and ureteral stones underwent laparoscopic removal of their stones. The indications for laparoscopy were; unavailability of pediatric PNL setup in two children, failed of SWL in one, renal stones with concomitant PUJO in one, and large impacted ureter stones in the rest of patients. Result: Stone largest diameter ranged from 25 to 45 mm (mean 28 mm), operative time ranged from one to 4 hours (mean 2.3 hours) and hospital stay ranged from four to seven days (mean 5 days). The procedure completed successfully an all, but one patient in whom conversion to open ureterolithotomy performed, because of difficulty to access the large impacted intramural stone, no major intra or post-operative complications, no blood transfusion needed. One patient develop prolonged urine leakage for 10 days managed conservatively. Follow up after three, six and 12 months with plain abdominal x-ray (KUB) ultrasonography (US) and Urography (IVU) when indicated showed no residual stones and no newly developed hydronephrosis. Conclusion: Laparoscopic surgery is safe and effective in management of large renal and ureter stones in patients who are not suitable candidate for endourology.

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The prevalence of obesity in Saudi Arabia was 28.7% in 2013, and similar to the west, laparoscopic sleeve gastrectomy (LSG) is nowadays one of the most commonly performed bariatric procedures in Saudi Arabia. Portal vein thrombosis (PVT) was at first thought to be a rare and potentially fatal occurrence postoperatively. Recent data suggest that it is much more prevalent following LSG of all other bariatric procedures, and prognosis is favorable given early diagnosis and treatment. The aim of this article was to describe three cases of PVT post-LSG encountered at our institution and provide a brief review of the literature.

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The rarity of malignant phyllodes leads to variability in diagnosis and management. Most of the reported cases in the literature are large malignant phyllodes tumor. Malignant phyllodes tumor was seen in the age group between 35 and 55 years. The youngest age reported was an 11-year-old girl. The eldest reported was an 89-year-old woman. Phyllodes tumors are characterized by a typical rapid growth. Phyllodes tumor are composed of epithelial element and connective tissue stroma with stromal increased cellularity, cellular atypia, and pleomorphism with increased mitosis. The most common path of spread is hematological mostly to the lung, pleura, bone, heart, liver, metastasis to the brain and adrenal have been reported. Palpable axillary lymph node is found in 10%–15% cases; only <1% of them is pathologically positive for malignancy. Surgery in the form of breast conservative or mastectomy remains the primary treatment of malignant breast phyllodes. No literature support axillary lymph node dissection. For breast conservative surgery (BCS), 1 cm free margin is recommended less than that will be associated with higher recurrence rate. Mastectomy is indicated only if tumor-free margin cannot be obtained by BCS. In multivariate analysis, patient with more adverse prognostic factors underwent postoperative radiation therapy (RT). The RT groups were not inferior to non-RT groups on cancer-specific survivor regardless of surgery (mastectomy or BCS). But post-operative radiation therapy for BCS will significantly reduce local recurrence. Post-operative chemotherapy is seeing increased in palliation of metastatic cases.

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Background and Objectives: This is a survey study of adverse events in the postanesthesia care unit (PACU) at the University Malaya Medical Center (UMMC). Patients and Methods: After obtaining the hospital ethics committee approval, 2704 patients who were operated and admitted to the PACU at UMMC were included in the survey. The survey period was from July 1, to September 30, 2005. The modified Aldrete score was used in the PACU. If it was <9 on a 10-point scale that was defined as a patient complication. A patient diagnosed with a complication was immediately notified by the recovery nurse to the attended anesthesiologist who managed the case, and a survey report was completed. Results: Nearly 9.7% reported incidents of adverse events included two accidents of cardiac arrests. The majority of which were due to hypothermia and cardiovascular instability. Most incidents were in American Association of Anesthetists 3 and 4 category. General surgery was associated with the highest incidents. Most of the incidents resulted in prolonged PACU stay. Conclusions: This study provides auditing information on adverse incidence in the PACU with issues of care delivery; besides, it highlights a roadmap for quality improvement for a better patient care.

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Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi. Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy. Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

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Background: Laparoscopic cholecystectomy (LC), gaining worldwide popularity for being less invasive, enhances earlier recovery. It can be performed on a short stay basis, reducing health care burden, if postoperative pain is adequately addressed. The aim of the present study is to determine the effect of intraoperative infusion of intravenous (IV) lignocaine primarily in terms of time to achieve fast-track eligibility (White Song score 12 out of 14) and postoperative analgesia in patients undergoing LC. Materials and Methods: A total of 120 ASAPS 1 and 2 patients undergoing elective LC were included in this randomized, prospective, placebo-controlled clinical study. Patients were allocated into two groups to receive intraoperative IV lignocaine (Group L) or normal saline (Group C). Lignocaine bolus dose 1.5 mg/kg was administered over a period of 5 min before induction followed by continuous IV infusion 3 mg/kg/h until extubation. Postoperative fentanyl requirement (during the first 6 postoperative hours) and fast-track eligibility (time to reach White Song score 12 out of 14) were recorded. Results: Time to achieve White Song score 12 out of 14 was found to be earlier in Group L (19.9 ± 3.6 min vs. 22.9 ± 2.9 min, P < 0.001). Postoperative requirement of fentanyl was significantly lower (99.3 ± 29.8 μg in Group L compared to 133 ± 35.9 μg in Group C, P < 0.001) in patients of lignocaine group. Conclusion: IV lignocaine effectively improves recovery and reduces postoperative fentanyl requirement, thereby is an inexpensive and safe method of postoperative analgesia.

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Gastrointestinal stromal tumors (GISTs) are rare tumors representing 0.1%–3% of all gastrointestinal cancers with an estimated incidence of 15/million. These tumors are characterized by the overexpression of the tyrosine kinase receptor KIT (CD117). The diagnosis of GIST has dramatically increased since 1992, and survival has greatly improved since 2002 when the Food and Drug Administration approved imatinib mesylate. Surgical treatment is the only chance of cure for patients with primary localized GIST. There is no surgical consensus about laparoscopic or open surgical treatment. However, the role for laparoscopy in the resection of GISTs continues to expand. The laparoscopic approach for gastric GISTs offers significant advantages in terms of postoperative pain, surgical trauma, and hospitalization, with the same oncological results obtained with open surgery while today it is considered the gold standard of treatment only for small gastric GIST. Controversy surrounds the maximum diameter of GIST for laparoscopic resection. We present our experience of 33 cases of GIST at Sant'Anna Hospital (Ferrara) in a period between 1999 and 2017 with a literature review.

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Background: The optimal method of hernia repair in children is still debatable in spite of a large number of clinical trials comparing open and laparoscopic repairs. Aim: The aim of this study is to compare laparoscopic versus open herniotomy with regard to a patient's perspective in terms of immediate postoperative recovery and comfort and long-term satisfaction with the procedure. Settings and Designs: This is a retrospective study from January 2014 to 2016 conducted at a tertiary care center. Materials and Methods: A total of eighty consecutive patients (forty open and forty laparoscopic) who underwent inguinal hernia repair were included in this study. Postoperatively on follow-up, which ranged from 6 to 20 months, the patient and/or parent were interviewed by a questionnaire. This included documentation of postoperative pain which was assessed by visual analog scales and face, legs, activity, cry, consolability scoring system according to the age of the child, time of discharge from hospital, postoperative complications and time taken to return to normal activities, recurrence of hernia or hernia on the opposite side, cosmesis, and problems associated with scars. Results and Conclusions: Patients in the laparoscopic group fared better than the open group in terms of postoperative pain, return to routine activities, and cosmesis. However, there was one recurrence on the same side in this group. No recurrences on the operated side were observed in the open group; however, three contralateral hernias were operated in this group.

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A myoepithelial hamartoma is a very uncommon submucosal tumor of the stomach. The exact pathogenesis and natural history of these lesions are not fully understood, possibly because very few cases have been reported in the literature. Gastrointestinal tract adenomyomas are generally considered to be benign and may present clinically with in part long-standing, but unspecific symptoms, such as pain, nausea, anorexia, and in some patients, they can cause intermittent pyloric obstruction. In an atypical presentation in our case, myoepithelial hamartoma mimicked the clinical presentation of a gastrointestinal stromal tumor.

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Postcholecystectomy bile duct injury (BDI) is a life-threatening complication; it associated with increased morbidity and mortality in addition to the medicolegal consequences. The most common cause of serious biliary injury is misidentification of cystic duct-common bile duct relationship. Many techniques had been tested by surgeons to avoid the misidentification injury, this include infundibular technique, critical view of safety, retrograde laparoscopic cholecystectomy, operative cholangiography, fluorescence cholangiography, and biliary navigation surgery using endoscopic nasobiliary drainage. Among these methods, critical view of safety (CVS) has been found most reliable and safe method for cystic duct identification. Moreover, it is easy applicable, fast to learn, and not required special equipment. If the CVS cannot be achieved safely, there are others alternative methods to avoid BDI according to SAGES recommendations.

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Aims: The aim of the present study was to evaluate the safety of laparoscopic cholecystectomy in patients with liver cirrhosis and portal hypertension. Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of six years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The diagnosis of cirrhosis was made based on preoperative workup, intraoperative findings, and histo-pathological study based on liver biopsy. The outcomes of laparoscopic cholecystectomy in patients with cirrhosis were compared to those without it with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them 42 patients were diagnosed to have features of cirrhosis and portal hypertension after laparoscopy and subsequently 36 were confirmed to have cirrhosis on histopathology. There were 15 males and 21 females in these 36 patients. The diagnosis of cirrhosis was established preoperatively in 21 patients. The operative time and hospital stay were significantly increased in the cirrhotic group. None of our patients in the cirrhotic group required conversion. Perioperative complications were seen more often in the patients with cirrhosis [5 (13.89%) versus 207 (6.69%); P value = 0.0126]. Ascites was the most frequent post-operative complication seen in cirrhotic patients. Conclusion: Laparoscopic cholecystectomy, though technically demanding in cirrhotic patients can be safely done even in a peripheral health set-up with acceptable morbidity rate.

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Introduction: The successful maintenance of peritoneal dialysis is the outcome of well functioning of the peritoneal catheter. Catheter outflow obstruction may cripple the usage of the peritoneal catheter. Catheter migration, omental entrapment, and fibrin clots are the usual causes of this failure. Oviduct fimbriae can cause obstruction rarely. Materials and Surgical Technique: We describe a case of a a 65-year-old woman, in whom the obstruction fimbriae was the cause of the obstruction and was managed by cleaning the catheter, and the right  fimbraepexy to the lateral wall of the peritoneal wall in the dependent part with no salpingectomy is required. Discussion: In follow-up of 20 months, the catheter is working; this technique can be used in young patients who need to balance the risk of infertility with the risk of malfunction of peritoneal dialysis catheter. Conclusions: Ovarian fimbria entrapment in the PDC is rarely the cause of dialysis flow obstruction, if occurs, laparoscopic management is ideal way to manage such presentation.

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Femoral hernias account for 3% of all hernias and can frequently present with incarceration of omentum, preperitoneal fat, small bowel and colon, and more rarely a Meckel's diverticulum or appendix. De Garengeot's hernia (GH) is a rare type of femoral hernia representing 1% of all femoral hernias and contains the vermiform appendix. The purpose of this report is to present a case of GH with discussion of the clinical findings along with description and details of the surgical technique applied for its repair.

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Introduction: Laparoscopic approach had enormously advanced the surgical intervention. Such advancement had its own difficulties. One of this is the visualizations of internal structures by the endoscopic camera. Camera lens condensation or contamination by blood and/or fat obscures such view. Materials and Surgical Technique: Here, we present an additional technique in which the use of sterile surgical strips by its specific absorptive and availability in different widths and lengths to clean the endoscopic entry ports with special focus over 5 mm ports that can be combined to the other well-known anticondensation methods for the overall better visualization. Discussion: Different modalities to clean laparoscopic entry ports have been described but with difficulties and associated risks and limitations. The use of sterile packing strips in cleaning laparoscopic ports avoids the disadvantages descried in other modalities and in the same time being easy, adjustable, and have low cost.

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Robotic surgery is a high technology minimally invasive system. Morgagni's hernia is a rare congenital diaphragmatic hernia subtype that occurs in relation to the sternum anteriorly. Classically, symptomatic Morgagni's hernia is repaired by open abdominal approaches to reduce the hernia contents and suture the defect primarily or by patching large defects with a synthetic mesh. Recently, authors advocate the use of laparoscopic surgical techniques to repair such hernias especially the elective ones. This case discusses Morgagni's hernia repair using robotic surgery.

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